Provider Demographics
NPI:1467447748
Name:DESANTIS, DAVID (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8860
Mailing Address - Fax:765-935-8859
Practice Address - Street 1:1350 CHESTER BLVD STE D
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1960
Practice Address - Country:US
Practice Address - Phone:765-935-8860
Practice Address - Fax:765-935-5589
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.065370207Q00000X
IN01044050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110144521OtherMEDICARE RR
INP00875846OtherMEDICARE RR
INDEC36280OtherCSHCS
IN000000681665OtherANTHEM
OH0943797Medicaid
IN200043690AMedicaid
INP00875846OtherMEDICARE RR
940940B2Medicare PIN
IN905920BMedicare PIN
IN905920BMedicare PIN